Background Information: Critical care and emergency medicine are frequently intertwined as the resuscitation of critically ill patients occurs in both environments. While the majority of these patients come through the emergency department (ED), the resuscitation of critically ill patients is not defined by a geographic location, but rather a set of principles designed to deliver appropriate care in a timely fashion.1,2 Increased numbers of critically ill patients in combination with decreased availability of intensive care unit (ICU) beds and a shortage of intensivists has led to a shift in critical care being delivered in the ED.3 Furthermore the lack of ICU beds, among many other factors, have contributed to a prolonged length of stay (LOS) of already admitted patients known as “ED Boarding”. Another factor to consider, is that providing prolonged critical care in a traditional ED setting is challenging as it requires more staff and is often associated with increased mortality. Multiple studies have demonstrated an association of worsened outcomes when patient’s ED LOS is greater than 6 hours and, in the United States, 33% of all ICU admissions from the ED have an ED LOS greater than 6 hours.1,4 A proposed solution has been the development of ICUs housed within the ED known as ED-ICUs. While only a handful exist, this new method of care delivery aims to reduce the time it takes for patients to receive critical care and offset the strain on current ICUs (Table 1)4. The authors of this study sought to determine the association of ED-ICUs on 30-day mortality and inpatient ICU admission....Read More
When looking at pH and bicarb, the differences between VBG and ABG are miniscule. For DKA patients, stick with the VBG as is less painful and has fewer complications.
LR is probably a better fluid for the large volume resuscitation required in DKA. Start with a 20 cc/kg bolus and then reassess the patient’s perfusion status.
Stay on top of your electrolyte repletion. If the patient has a working gut, you can aggressively replete potassium orally and don’t forget that when you are repleting potassium you also must replete magnesium.
Bolus dose insulin gets the patient to super-physiologic levels and has been associated with higher potassium requirements and more episodes of hypoglycemia. It’s probably fine to skip the bolus and stick with a drip alone
Don’t forget to think of all possible etiologies of DKA, while we most often find this in patients who have not been taking their home meds for whatever reason, don’t forget a good history to look for sources such as infection and ischemia.
Background: Supraventricular tachycardia (SVT) is not an uncommon condition in the emergency department. Epidemiologically, SVT has an incidence of 35/100,000 person-years in the United States.2That is roughly 89,000 new cases per year. The Valsalva maneuver is a recognized treatment for SVT, but has a low success rate (5-20%). 3,4,5 The REVERT trial showed an increase in cardioversion of SVT using a modified Valsalva maneuver, but this was done with a manometer, and adjustable bed, which may not be available in many settings....Read More
Shock is defined as circulatory failure leading to decreased organ perfusion. In a shock state there is an inadequate delivery of oxygenated blood to tissues that results in end-organ dysfunction. Effective resuscitation includes rapid identification and correction of inadequate circulation. the finding of normal hemodynamic parameters (i.e. normal blood pressure) doe not exclude shock itself. In this 11 minute and 40 second video, I will review the management shock - part 1 (The goals of shock management, signs of adequate organ perfusion, the etiology of shock, and some basic terminology).
Background: Rapid sequence intubation (RSI) involves the use of an induction agent followed by a neuromuscular blocking (NMB) agent to obtain optimal intubating conditions. Administration of a NMB results in apnea which, in turn, can lead to oxygen desaturation. Oxygen desaturation during rapid sequence intubation may lead to serious adverse events including dysrhythmias, hypotension, and cardiac arrest. Preoxygenation helps extend the duration of safe apnea and has 2 major goals:
Attempt to achieve an O2 saturation of 100%
Maximize oxygen storage in the lungs by denitrogenation of the residual capacity of the lungs (Approximately 95% of oxygen reservoir)
Preoxygenation is assessed in the ED but usually through pulse oximetry which is inadequate. In the operating room, anesthesiolgists use gas analyzers to quantify and optimize preoxygenation with ETO2. In critically ill patients, preoxygenation should be performed to achieve an ETO2 ≥85% based on the response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society ....Read More